TRUE Physical Therapy, LLC
....TRUE PT listens, teaches, guides YOU to help yourself !
628 Shrewsbury Ave Tinton Falls NJ 07701
Teresa A. Ryan PT, DPT Lic# QA05476
Steven J. Ryan PT, Cert. MDT Lic# QA07294
Online Registration Form: ONLY AFTER APPOINTMENT MADE PLEASE
Have you had any physical therapy this calendar year?*
How did you hear about TRUE Physical Therapy?
How did you hear about us?
Consent For Assessment, Treatment and Releases
- I hereby authorize TRUE Physical Therapy, LLC by appropriate personnel to perform or have performed upon me (or named patient) such assessment and treatment procedures as are deemed necessary.
- I authorize the release of any information including but not limited to diagnosis and treatments rendered to my (patient’s) insurance company, adjuster, attorney and/or other health practitioner.
- I understand and authorize, that at times it will be necessary for this Office to call my home or place of business and leave messages on voicemail or email.
- I certify that the information provided on these pages is true and correct to the best of my knowledge. Furthermore, I certify that I have been offered/ will receive notification of the company’s Notice of Privacy Practices and grant permission for electronic transmission of billing/documentation.
TRUE Physical Therapy, LLC appreciates the confidence you have shown in choosing us to provide for your rehabilitative needs. At TRUE Physical Therapy “service” is our business. We consider health care to be a team effort between the patient, the physician (if involved) and us. It is a service in which you have elected to participate, which implies a financial responsibility on your part to TRUE Physical Therapy, LLC. It is a responsibility that requires you to ensure payment in full of our fees.
It is our goal to provide our patients with the best quality of rehabilitative care at a reasonable cost, while still providing full service, such as billing directly to your insurance carrier on your behalf in some cases. In today’s healthcare marketplace, coverage for physical therapy varies greatly and is not always a covered service. While we strive to provide EXCEPTIONAL CARE, we are unable to do so without reimbursement and therefore have ceased agreements with the majority of insurance carriers. We continually pledge to provide the MOST cost effective and appropriately utilized approach towards your health and well being, understanding financial constraints of both patient and our practice.
TRUE Physical Therapy, LLC is not liable for incorrect data provided by your insurance carrier.
Please indicate your type of coverage:
For your benefit, an explanation of insurance coverage is provided below.
* Indicated Required Fields
Medicare as your primary coverage: We are non-participating providers with Medicare and will bill Medicare directly for you. You are responsible for the full payment of services when rendered. TRUE Physical Therapy, LLC agrees to abide by the Medicare fee schedule and will submit the necessary forms to Medicare for your reimbursement. Medicare will then submit to your supplemental insurer. In some cases, you will need to submit for your secondary insurance. (Medicare supplements or other indemnity plan). If your insurance carrier denies coverage, we hold no responsibility for the payments provided for rendered services.
Out of Network as your primary coverage: TRUE Physical Therapy, LLC is an out of network provider with almost all insurance carriers. Services will be provided to and paid for by the client, and we will provide a statement for you to submit to your health insurer accordingly for reimbursement. Please respectfully understand, it DOES matter where you are treated and often times no better investment dollar return than your health is realized. We value your health.
In Network as your primary coverage: Health insurance issues are complex, confusing and frustrating for all of us. That said, TRUE PT only participates with limited insurers. This allows us to continue providing quality, value priced effective therapy for you, our client. If we do participate with your insurer, we shall submit for services rendered and accept payment. You are responsible for any/all deductible, coinsurance and copayment as stipulated by your insurer. Please know we make every effort to contain cost and respect your time, investment and efforts as well as ours.
No Insurance Coverage/Self Pay Option: In this case, there is no insurance coverage available for you to receive services rendered at TRUE Physical Therapy, LLC. Therefore, you agree to self-pay at the rates determined and outlined to you by TRUE Physical Therapy, LLC.
I have read the above policy regarding my financial responsibility to TRUE Physical Therapy LLC, for providing rehabilitative services to me or the individual named below. I agree to pay TRUE Physical Therapy, LLC the full and entire amount of all bills incurred by me or the individual named below; or any amount due after payment has been made by my insurance carrier.
I understand that it is my full responsibility to inform TRUE Physical Therapy, LLC of any correspondence that I receive from my insurance company notifying me of a change or cessation of payment of physical therapy bills.
Physical Therapy benefits are quoted to TRUE Physical Therapy, LLC by my insurance carrier. These benefits are subject to the terms and conditions of my policy and are not a guarantee of payment. TRUE Physical Therapy, LLC is not responsible or liable for any incorrect data provided by the insurance carrier during the Insurance verification process. In addition: I authorize my insurance company (if applicable) to pay benefits directly to TRUE Physical Therapy, LLC.
- I am financially responsible for any non-covered services provided by TRUE Physical Therapy, LLC.
- I authorize TRUE Physical Therapy, LLC to release medical information required for billing.
- I understand that the bill for any scheduled physical therapy appointments not canceled at least 24 hours prior, excluding emergencies or situations approved by my therapist, shall be paid for by me.
Please click to agree to the above statement and submit your information to TRUE Physical Therapy, LLC
If other, please explain:
If coming in directly, please type NONE.